ICF in riabilitazione: possibili utilizzi

1. ICF in riabilitazione: possibili utilizzi Mauro Zampolini

2. L’ICF non è un sistema di misura • La misura e un processo di assegnazione di numeri per rappresentare quantità di oggetti, attività, caratteristiche, comportamenti etc.

3. in MR si valuta l'outcome Johnston, 2005

4. AMBIENTE PERSONA Quale e cosa è l’outcome in riabilitazione? La JCAHO (Joint Commission for the Accreditation of Health Care Organizations) americana ha definito gli outcome della riabilitazione come "il ripristino, il miglioramento o il mantenimento del livello ottimale del paziente riguardo al funzionamento, la cura di se, l’auto- responsabilità, l'indipendenza e la qualità di vita" funzionamento Ne deriva che gli indicatori di outcome riabilitativo non possono che essere misure comportamentali, esattamente come gli indicatori di prestazione scolastica o gli indicatori di attitudine e di stati cognitivi e psicologici.

5. How to assess functioning??? Functioning is the starting point of rehabilitation Comprehensive approach It requires a common and comprehensive understanding of functioning Multidisciplinary approach

6. AMBIENTE PERSONA Funzione:interfaccia persona-ambiente FUNZIONI BIOLOGICHE FUNZIONI PSICO-COGNITIVE Valutazione Funzionale COMPORTAMENTO MOTORIO COMPORTAMENTO COMUNICATIVO ENERGIA-MOVIMENTO (±%) COMUNICAZIONE (±%)

7. Funzione – l’esperienza individuale

8. Funzione – l’esperienza individuale Andare al Bagno Michael, 20 3 months following traumatic paraplegia „The most difficult thing for me at the moment is that I am not able to simply go to the toilet anymore. And for me, this is the most difficult thing to accept.“

9. Funzione – l’esperienza individuale Uso della mano e del braccio Ingrid, 37 4 months following traumatic tetraplegia „I am really dependent on others, I am not even able to open the purse by myself. …and maybe this is the reason not to go out to meet other people.“

10. Funzione – l’esperienza individuale Martin, 26 5 months following traumatic complete paraplegia “The major problems for me at the moment are to find a wheelchair accessible accommodation and how to manage the wheelchair in locations with many obstacles.” Spostarsi in diversi luoghi

11. Funzione – l’esperienza individuale Autosufficienza economica Mr Dee, 41 years 2 months following traumatic SCI „To have an income is very important for me. I am very much worried about having enough money in the future to purchase goods and to support my family. But therefore I need to gain functions to be able to work in my occupation as a farmer.“

12. Funzione – l’esperienza individuale Impiego pagato Lisa, 36 Four months following traumatic paraplegia „My goal for the future is to practice my former profession again …and to exercise any kind of sport“

13. Funzione – l’esperienza individuale d850 Impiego pagato Uso mano e braccio d445 d870 Autosufficienza economica Andare al bagno d530 Spostarsi in diversi luoghi d460

14. Come valutare il funzionamento? Per facilitare gli approcci basati sulla valutazione e miglioramento di una funzione, occorre che operatori sanitari, e non, usino un linguaggio comune

15. 2 aspetti sul linguaggio comune… Quali sono le «parole» di questo linguaggio ? Che vuol dire usare un linguaggio comune ?

16. 300´000 - 600´000 words • The ICF dictionary • Names, codes, and descriptions of categories which enable us to communicate about the human experience in relation to functioning and disability • Dictionaries of human languages • Words and descriptions of these words which enable us to communicate all aspects of the human experience

17. How many „elements“/“words“ do we need to comprehensively describe or classify the human experience of functioning and disability? 1454 ICF categories

18. How many of the 1454 ICF categories do we need in clinical practice or research? • How many of the 300´000 - 600´000 words of a spoken language do we need in day-to-day reality? • 2000 words cover 85% of the spoken language • with additional 2500 words one covers 95%!

19. Strategia dei Coreset Brief ICF Core Sets Comprehensive ICF Core Sets • Research &Clinical encounter (by a single profession) • Approximately 10-20 • Multi-disciplinary assessment (by a team) • approximately 70-150 Selection depends on • Health condition (dementia vs headache vs stroke) • Context (acute, postacute, long-term; age)

20. Comprehensive ICF Core Set List of ICF categories that includes as few categories as possible to be practical, but as many as necessary to describe the typical spectrum of problems in functioning of patients with a specific condition in a comprehensive, multidisciplinary assessment

21. A common language for different settings Rehabilitative Strategy Curative Strategy Acute context Acute curative care Acute rehabilitation Post-acute context Subacute supportive care Postacute rehabilitation Long-term context Primary care Community based Rehabilitation Lifetime support Stucki G et al. ICF-based classification and measurement of functioning Eur J Phys Med Rehabil 2008; 44: 317-330

22. Senza un linguaggio comune ogni struttura potrebbe scegliere un proprio modo di valutare il soggetto, così da avere NON valutazioni orientate al paziente, ma orientate al centro. • Del parametro/scala • Del paziente • Dell’esaminatore • Del setting (palestra, letto, domicilio, etc) • Del tempo (ad es prima o dopo fisioterapia) • Organizzare la documentazione scelte criticità

23. Secondo un recente articolo del gruppo di Stucki ogni percorso riabilitativo, proprio perché fondato sulla riacquisizione dei vari “funzionamenti” della persona, può essere strutturato secondo la logica del problem solving , che integra condizioni di salute con obiettivi, proposte di trattamento, tempi ed operatori. paziente setting outcome MISURARE tempo esaminatore Come unificare le variabili

24. La loro proposta è quella di utilizzare i codici ICF . Ciò permette che la valutazione: • Abbia un linguaggio comune tra i vari operatori • Abbia un linguaggio comune tra i vari setting • Sia valida per ogni persona indipendentemente da età, popolazione etc • Tenga conto di fattori contestuali • Vi siano supporti confrontabili trai vari istituti

25. Rehab-CYCLE • Il loro modello è stato definito Rehab-CYCLE , formato da cicli modulari (all’interno dei quali si stabiliscono dei “cycle goals”) che seguono l’evoluzione del paziente in tutto il suo percorso, dalla fase acuta all’eventuale rientro domiciliare. Rauch et al , 2008

26. Society level Provider level Service Program Goal e.g. acute hospital Service Program Goal e.g. early post-acute rehab-facility Service Program Goal e.g. In-patient rehabilitation Service Program Goal e.g. Out-patient rehabilitation Practice level Cycle goals Cycle goals Cycle goals Cycle goals Cycle goals Cycle goals Cycle goals Cycle goals Time Level of goal definition Activity and participation Body functions and body structures Definition of goals and intervention targets Hierarchic structure of rehabilitation goals Global Goal

27. Rehab-CYCLE Ogni step è articolato in 4 punti essenziali: • valutazione, • assegnazione • identificazione • rivalutazione Rauch et al , 2008

28. valutazione • La valutazione dello stato di funzionamento può essere fatta con una scheda in cui si ha il profilo ICF del paziente, evidenziando in una lista di categorie quelle coinvolte ed in che grado lo sono. • La rilevazione dei problemi viene effettuata con un metodo di linkaggio che unisce l’osservazione del dato alla corrispondente categoria ICF.

29. Vediamo come può essere costruita

30. Patient’s perspective – from patient’s history Health professional’s perspective – from clinical examination and specific test, observations

31. My bowel and bladder do not work anymore I am not able to take a shower by myself To maintain in a sitting position is problematic My bodyweight loss bothers me To dress the lower extremity is impossible, the T-Shirt, I slowly get under control I am not able to sense my body anymore I am not able to walk anymore I have slight pain when I move my trunk To transfer myself is quiet difficult I am able to catheterize myself, but I need support to purge the bowel I have spasticity in my legs To move the wheelchair uphill and overcoming barriers is a problem I am not able to work in my job My blood pressure decreases very often It is important for me to meet my friends I have to sleep on my back, that bothers me I have a little pressure ulcer at my right heel Health professional’s perspective – from clinical examination, specific tests, observations The compression hosiery helps a little bit The flat is not wheelchar accessible 26- year old man Mover The support of my parents and friends is a very big help for me My willpower is extremely strong

32. An ICF Qualifer rates the extent of an impairment, limitation or restriction and the extent of the facilitator or barrier

33. Use of ICF Qualifiers ICF Activity & Participation d Body Function b Body Structures s Environmental Factors e PersonalFactors 0 NO barrier 1 MILD barrier 2 MODERATE barrier 3 SEVERE barrier 4 COMPLETE barrier 0 NO facilitator +1 MILD facilitator +2 MODERATE facilitator +3 SEVERE facilitator +4 COMPLETE facilitator 8 not specified 9not applicable 8 not specified 9not applicable

34. Perform a clinical test, • examination, observation • or interview b280 Sensation of pain 2. →Rate the result within the ICF Qualifiers Moderate = ICF Qualifier 2 VAS 4/10 = 40% of the problem = ICF Qualifier 2 3. → Enter the results in the ICF Categorical Profile Result: PT: Martin is suffering from moderate pain (VAS Scale: 4) in his back, apparently related to movement in his trunk. moderate pain (VAS Scale: 4) in his back

35. Perform a clinical test, • examination, observation • or interview b280 Sensation of pain b620 Urination functions 2. →Rate the result within the ICF Qualifiers 3. → Enter the results in the ICF Categorical Profile Complete problem= ICF Qualifier 4 Result: Nurse: Martin‘s urination functions do not work at all. He is completely incontinent. urination functions do not work at all. completely incontinent.

36. Perform a clinical test, • examination, observation • or interview b280 Sensation of pain 2. →Rate the result within the ICF Qualifiers b620 Urination functions d420 Transferring oneself Fairly limited= ICF Qualifier 2 SCIM 1 = half of full function = ICF Qualifier 2 3. → Enter the results in the ICF Categorical Profile Result: OT: Martin is fairly limited in transferring himself from the wheelchair to the bed and back. Sometimes he needs partial assistance, but at least supervision (SCIM: 1) fairly limited in transferring himself (SCIM: 1)

37. Perform a clinical test, • examination, observation • or interview 2. →Rate the result within the ICF Qualifiers contribute partially= ICF Qualifier 2+ 3. → Enter the results in the ICF Categorical Profile Result: OT: Martin already has some products to support him with respect to his mobility. Nevertheless they contribute to his mobility only partially. The wheelchair is quiet good adapted but the car not at all. Hence, these factors have to be optimized. some products to support him contribute to his mobility only partially. d120 Products and technology…for personal… mobility

38. Quali sono i CYCLE GOALS ? • Una volta identificati i vari problemi occorrerà valutare: • Quali hanno una ricaduta positiva e negativa • Quali di questi sono rilevanti per il paziente • Quali sono modificabili • Su quali di questi può lavorare il team , in base alle sue caratteristiche, al contesto ed alla fase della patologia

39. Community integration 0 1 Independence in daily living Mobility 1 1 Self-Care 3 Vocational reintegration

40. Assegnazione • Significa collegare gli obiettivi al tipo di intervento e questo ad un professionista sanitario che diverrà responsabile del modo di operare e del raggiungimento dell’obiettivo • Strumento: ICF assignment maps

42. intervento • Il responsabile sceglie le tecniche di intervento che ritiene più adatte (es:il medico sceglie che FANS dare per una infiammazione e a che dosi • Metodo: sull’esperienza o basato su approcci teorici • Inoltre potrà scegliere gli strumenti specifici per la valutazione iniziale, per i progressi e per la valutazione finale

43. Valutazione

44. X 2 3 0 1 2 2 3 0 0 1 0 1 0 1 1 1 b280 Sensation of pain X X b4202 Maintenance of blood pressure X X b710 Mobility of joint functions b7300 Power of isolated muscles b7305 Power of muscles of the trunk b7353 Tone of muscles of lower half b755 Involuntary movement reactions s810 Structure of areas os skin 3 2 2 2 4 1 2 4 3 2 4 2 1 1 1 0 2 0 1 2 0 1 3 2 d410 Changing basic body positions • Assign different health • professionals to each • intervention target d4153 Maintaining a body position d420 Transferring oneself d465 Moving around using equipment d475 Driving d510 Washing oneself d520 Caring for body parts d5301 Regulating defecation d540 Dressing d570 Looking after one‘s health d850 Remunerative employment d920 Recreation and leisure e115 Products and techn. for use in daily 3+ 2+ 4 4+ 4+ 2 e120 Products and techn. for mobility e155 Design, construction of buildings pf Coping with disease + - - + 0 0 pf Acceptance of emotions pf Self competencies

45. X Manual therapy 2 3 0 1 2 2 3 0 0 1 0 1 0 1 1 1 b280 Sensation of pain X X Medication, Compression hosery b4202 Maintenance of blood pressure X X Active and passive movement of joints b710 Mobility of joint functions b7300 Power of isolated muscles b7305 Power of muscles of the trunk b7353 Tone of muscles of lower half b755 Involuntary movement reactions s810 Structure of areas os skin 3 2 2 2 4 1 2 4 3 2 4 2 1 1 1 0 2 0 1 2 0 1 3 2 d410 Changing basic body positions 2. Assign appropriate interventions to each intervention target d4153 Maintaining a body position d420 Transferring oneself d465 Moving around using equipment d475 Driving d510 Washing oneself d520 Caring for body parts d5301 Regulating defecation d540 Dressing d570 Looking after one‘s health d850 Remunerative employment d920 Recreation and leisure e115 Products and techn. for use in daily 3+ 2+ 4 4+ 4+ 2 e120 Products and techn. for mobility e155 Design, construction of buildings pf Coping with disease + - - + 0 0 pf Acceptance of emotions pf Self competencies

46. X Manual therapy 2 3 0 1 2 2 3 0 0 1 0 1 0 1 1 1 b280 Sensation of pain X X Medication, Compression hosery b4202 Maintenance of blood pressure X X Active and passive movement of joints b710 Mobility of joint functions X Muscle power training with equipment b7300 Power of isolated muscles X Muscle power training without equipment b7305 Power of muscles of the trunk Medication, Hippotherapy, Water therapy X X b7353 Tone of muscles of lower half Movement reaction training X b755 Involuntary movement reactions X Skin control, Education for skin care s810 Structure of areas os skin X X X Training of activites of daily living 3 2 2 2 4 1 2 4 3 2 4 2 1 1 1 0 2 0 1 2 0 1 3 2 d410 Changing basic body positions X Muscle power training, movement reaction tr. d4153 Maintaining a body position X X X Training of activites of daily living d420 Transferring oneself X Wheelchair training d465 Moving around using equipment X Driving training d475 Driving X Training of activites of daily living d510 Washing oneself X Training of activites of daily living, Counselling d520 Caring for body parts X Training of bowel management, Counselling d5301 Regulating defecation X X Training of activites of daily living d540 Dressing X X X X X X Education, Counselling, d570 Looking after one‘s health X Vocational training d850 Remunerative employment X Choice and adaptation of assistive devices e115 Products and techn. for use in daily 3+ 2+ 4 4+ 4+ 2 X X Choice and adaptation of wheelchair e120 Products and techn. for mobility X X X Clarification of living situation (private build.) e155 Design, construction of buildings X Other psych. therapy, Psych. counselling pf Coping with disease + - - + 0 0 X Other psych. therapy, Psych. counselling pf Acceptance of emotions X Other psych. therapy, Psych. counselling pf Self competencies

47. rivalutazione • La valutazione finale deve riflettere gli interventi compiuti • Ogni professionista esamina i risultati del proprio settore e riporta in sede multidisciplinare i risultati • Overview sul percorso realizzato (ved tabella) • Nuovi obiettivi

48. 0 Community integration Independence in daily living 1 1  Mobility  1 Self-Care Vocational reintegration  3 CG1 0 -  1 CG1 0  CG1 - 0 CG1  1 CG1 CG1 1 - CG1 1  CG2 0  1 CG1, 2  CG1, 2  1  1 CG1, 2 CG1 0  - CG1 2 CG2 0  CG2  1 CG2 2   CG2 0 1  CG2 GG 3   2 GG CG2  4+ - 4+ CG1  GG 2  SPG + 0 SPG   0 SPG

49. ICF Analizza e scompone la complessità Organizza l’osservazione nel team Da un ordine possibile agli strumenti di misura Migliora il livello della valutazione Guida gli interventi riabilitativi È supporto per il follow-up

50. buon lavoro con l'ICF!